Paediatrics
Spinal
ISSUE 22
June 2010
Injuries
ECGs & Trauma
Clinical
update
Have You Seen?
Medical Director’s
Bulletin
Treatment of Taser
Patients
15/04/2010
Oxygen Alerts
17/03/2010
Ambu Spur Bag & Mask
18/02/2010
Clinical Equipment
Update
05/02/2010
Pan London Stroke
Pathways
26/02/2010
Operations Bulletin
Blue calls: Changes in
process and launch of
major trauma networks
01/04/2010
Past Issues of the Clinical
Update can be found on The
Pulse under News > Local
newsletters > Clinical updates
http://thepulse/news/105793447
0.html
Reminders
Major Trauma – Patients going to a major trauma centre as they have met the criteria on the trauma
decision tree should have a blue call placed via channel PD09. The Clinical Coordination Desk will be
able to provide advice around major trauma. If the patient meets the criteria on the decision tree for major
trauma and is going to a major trauma centre, the relevant code should be used on the PRF (available on
the updated PRF code card on the pulse under Patients > PRF Assignment Record and Clinical Record
Form (LA4) http://thepulse/patients/12726213312124.html) even if the patient is within the normal
catchment of the major trauma centre.
Hyper Acute Stroke Unit and Cath Labs – Patients being taken to a cardiac catheterisation lab or
Hyper Acute Stroke Unit should have there blue call placed via the Clinical Coordination Desk on PD09.
Left Bundle Branch Block – Any patient who presents with ‘classic’ cardiac chest pain and has LBBB
(wide QRS complex and no q wave in lead V6) on their 12-lead ECG may be taken direct to the nearest
cardiac catheter lab for expert assessment. It must be stressed that the patient must have ongoing
cardiac chest pain that you believe might be that of an acute MI. Patients who present with
breathlessness or arm pain/silent MI and have LBBB should not go direct to the catheter lab.
Care when in custody suites – Staff are reminded to take extreme care when working in custody
suites, taking particular care with objects that may potentially be able to be used as a weapon. Take
great care to ensure that sharps are disposed of immediately post use. Objects such as scissors should
be returned to equipment bags / holsters once used.
Neonatal resuscitation masks for the bag and mask – Staff are reminded that neonatal-size masks
are available to order on ESeries and should be stored along with the paediatric bag and mask in the
oxygen bag and not in the PALS kit to allow easy access.
JRCALC National Clinical Guidelines correction of typographical error “Rectal Diazepam”
Age per page guidelines
In ages 6-11 years: where it states ‘1 x 10ml tube’ this should read ‘1 x 10mg tube’.
In ages 12 months- 5 years - where it states ‘1 x 5ml tube’ this should read ‘1 x 5mg tube’.
In ages birth - 9 months:
•
where it states CONCENTRATION ‘2.5mg in 2.5ml’ this should read ‘2.5mg in 1.25ml’
•
where it states ‘1 x 2.5ml tube’ this should read ‘1 x 2.5mg tube’.
Drug guideline (A4)
Child <1 year:
•
where it states CONCENTRATION ‘2.5mg in 2.5ml’ this should read ‘2.5mg in 1.25ml’
•
where it states ‘2.5ml (1 tube)’ this should read ‘1 x 2.5mg tube’.
Clinical update
Spotting the sick child
The Service attends around 50,000 under fives
each year. Figure 1 shows the number of
incidents that relate to children under five. Of
note is that the Service attends far more
children in the first years of their life than older
children. Assessing paediatrics can be
challenging, but sticking to a number of key
principles will help.
There are a number of key anatomical and
physiological differences between adults and
children and understanding these differences is
paramount when assessing children. Children
have a relatively large tongue in comparison
with adults which occupies much of the
oropharynx. Some texts suggest this is why
children are obligate nasal breathers. The
paediatric trachea is both narrow and softer
than the adult trachea as the C shaped
cartilage rings have not matured. The more
pliable trachea is at increased risk of
compression and can occlude with hyper
extension/flexion of the neck. In addition, due to
the relatively narrow lumen only a small amount
of swelling is needed to comprise the airway. In
addition to this the epiglottis is comparatively
larger than in adults and the larynx is higher
and more anterior.
In children the bones are more flexible than in
adults as they have yet to completely calcify.
This means that in chest injuries significant
underlying organ damage may occur without
concurrent fractures. The ribs of a child also run
more horizontal than in adults resulting in little
leverage to increase the anterior and posterior
diameter of the chest. This does not facilitate
the degree of lift that is necessary to increase
the volume of air within the chest when it is
needed. The heart of a child occupies a
proportionally larger area of the thoracic cavity
leading to relatively smaller lungs which also
decreases respiratory reserve of the child. In
children the abdominal cavity is tightly packed
with organs restricting the level to which the
diaphragm can descend, this again restricts
how the respiratory system compensates for
increased demand.
In the foetus the placenta provides
oxygenation. There are various shunts within
the circulatory system to allow for this. At birth
the lungs expand and take over oxygenation
and within the first days of life the ducts should
close. Initially in the neonate the pulmonary
resistance is high, as this drops the left
ventricular pressure becomes dominant.
The total circulating blood volume per unit of
body weight is greater than an adult by 25 per
cent. The body surface area of the child is
reported to be four times that of an adult yet
heat production does not increase thus
creating an increased risk of hypothermia.
This is one of the reasons why the metabolic
demand for children is proportionally higher
than in adults. As a result, the increased
metabolic demand and the fluid requirements
of the child are increased.
The liver of an infant or a child has yet to
develop fully and therefore has lower glycogen
stores increasing the chances of
hypoglycemia. The importance of capillary
blood glucose testing in children should not be
underestimated. Much of paediatric
assessment follows a similar pattern to that of
an adult and should take into account the
child’s age. The Paediatric Assessment
Triangle (Figure 2) has been proposed as a
useful aid when assessing children to gain a
general overall impression, but does not
negate a more detailed assessment. Each side
of the triangle represents a key component of
paediatric assessment, developed by the by
the American Academy of Paediatrics it can
provide a quick general impression of the
child’s condition.
Figure 2
Appearance
Assess the child from across the room to
gain a general impression of the child. The
TICLS (Figure 3) acronym provides a
useful guide to what you should expect in
a healthy child.
Work of breathing
Assessing the work of breathing reflects
the child’s attempt to compensate for
difficulties in oxygenation and ventilation.
Assessing respiratory effort should go
beyond the rate and depth assessments of
adults and must look at the effort of
breathing (see figure 5). This should be a
‘hands off’ assessment and may require
examination of the chest of the child at
skin level to ensure this is not missed. This
may mean asking the parent to briefly
undress the child explaining why this
needed.
Circulation to skin
This reflects the adequacy of cardiac
output. Inspect the skin (i.e. face, chest,
abdomen) and mucous membranes (lips &
mouth) for colour in central areas. In dark
skinned children, the lips and mucous
membranes are the best places to assess
circulation.
Tone
Extremities should move spontaneously,
with good muscle tone; should not be
flaccid or move only to stimuli
Interactiveness
Should respond to environmental stimuli
or presence of a stranger; should not be
listless, obtunded or lethargic
Consolability
Easily comforted or calmed by caregiver
Look/Gaze
Should maintain eye contact with objects
or people; should not have a “nobody
home” or glassy-eyed stare
Speech/Cry
Should be present, strong and
spontaneous; should not be weak,
muffled, or hoarse
Figure 3
Clinical update
Assessment of the airway should include listening to the noises made
by the child on respiration and is helpful in determining any
compromise of the airway. Nasal flaring and snorting is a frequent
finding, with chest recession noted in airway compromise. Neonates,
who are obligate nasal breathers, often experience serious respiratory
distress with nasal obstruction. Older children with nasal obstruction
characteristically breathe with their mouths open. Feeding is often
difficult or impossible, and patients may be unable to handle their own
saliva and may drool. Children can have slightly irregular respiratory
patterns, so counting the respiratory rate over 30 seconds will provide a
more accurate respiratory rate than counting over 10 or 15 seconds. As
well as assessing the work of breathing, auscultating the chest will
provide vital information around the patient’s respiratory condition.
When auscultating the chest of a small child listening in the mid axillary
line will reduce transmitted sounds from the opposite lung. Assessment
should consider the effort of breathing including looking for intercostal
recession (figure 4), nasal flaring, and in the older child the tripod
position all of which indicate effort of breathing.
Work of breathing features to look for:
Abnormal airway sounds Snoring muffled or hoarse speech,
stridor, grunting, wheezing
Abnormal positioning
Sniffing position, tripoding, refusing to
lie down
Recession
Supraclavicular, intercostal, (Figure 4)
or substernal recession of the chest
wall; head bobbing in infants
Flaring
Nasal flaring
Taken from PEEP 2002
Figure 5
Respiratory noises
Wheezing
Indicates lower airway narrowing and is most
commonly heard on expiration.
Stridor
Can indicate an imminent danger to the airway
due to reduction in airway circumference to
approx 10 per cent of normal.
The volume of stridor or wheeze is not an
indicator of severity and indeed may diminish
because less air is being moved.
Grunting
Figure 4
Pulse oximetry can be an important measure when assessing the
unwell child and provides a useful adjunct to clinical assessment.
Remember that most children without underlying health problems will
have very good saturations and even what may be considered normal
in an adult, for example a reading of 95 per cent would be notably low
for a healthy child. A child who appears unwell despite a normal
saturation reading may still be significantly unwell.
As with all vital signs normal pulse rates in a child will vary with age
(see table 1) although the actual pulse points are the same as in adult.
In small children the brachial pulse may be easier to find. If finding a
pulse is still difficult, listen with a stethoscope to determine heart rate.
In children the most common reason for bradycardia is hypoxia and
simple methods of opening the airway and basic airway adjuncts to
improve oxygenation can correct bradycardia.
As well as assessing the pulse, a capillary refill test should be carried
out. Remember if the child has cold limbs the capillary refill should be
done using a central location such as the sternum. Although blood
pressures can be difficult to obtain in children they can be a useful
determinant of shock. A normal blood pressure can be misleading as
children can compensate well. Also look for reduced skin turgor which
can indicate dehydration.
Circulation to skin
Characteristic
Features to look for
Pallor
White of pale skin/mucus
membrane colouration
Mottling
Patchy skin discolorations due to
vasoconstriction
Cyanosis
Bluish discoloration of skin and
mucus membranes
Is produced by exhalation against a partially
closed glottis. This is a sign of severe
respiratory distress and characteristically seen
in infants.
Taken from JRCALC National Clinical Guidelines 2006
When assessing circulation also consider dehydration. When did the
child last eat and drink? Has the child been to the toilet to urinate or
have the child’s nappies been wet?
Assessment of disability should consider the general appearance of
the child looking both at the level of consciousness, with either the
AVPU scale or the paediatric modified Glasgow Coma Score, and
assessing the tone of the child. A floppy /atonal child is a serious
concern. Pupils should be checked along with consideration of any
photophobia. The very gentle palpation of the fontanelles may reveal
bulging fontanelles, a sign of increased intracranial pressure. Sunken
fontanelles may indicate dehydration. The fontanelles close at around
two years of age.
A proper exposure of the child allows for careful examination of the
skin looking carefully for rashes and injuries. Care needs to be taken
to avoid heat loss. A non blanching rash is indicative of
meningococcal septicaemia (see figure 5). Remember that a child can
be seriously ill with meningitis without a rash or with a blanching rash.
Age
Respiratory Rate
Pulse Rate
<1 year
30-40 breaths per minute
110 -160 beats per minute
1-2 years
25-35 breaths per minutes
110 -150 beats per minute
2-5 years
25-30 breaths per minute
95 -140 beats per minute
5-11 years
20-25 breaths per minutes
80 -120 beats per minute
Taken from PEEP 2002
Table 1
-3-
Clinical update
Other components of paediatric assessment
Medical history:
Consider any medical history including whether the child was born
prematurely.
Contact with other unwell individuals:
Has the child been in contact with any one else who has been
unwell?
Medication/allergies:
Has the child been taking any medication or does the child have
any allergies to medication?
Toxicological:
Has the child had access or exposure to any potential harmful
substances?
Development:
Has the child reached the expected developmental milestones?
Immunisation:
Is the child up to date with immunisations?
Social/environmental:
Are there any social or environmental factors to note?
Safeguarding:
Are there any safeguarding concerns? The NICE guidelines
http://guidance.nice.org.uk/CG89 provide a useful guide to spotting
safeguarding concerns.
Figure 5
Benzylpenicillin use
in the Service
Background
The Clinical Audit and Research Unit (CARU) have recently carried out a clinical audit into the use of benzylpenicillin in the Service.
Benzylpenicillin was introduced into the Service for the treatment of suspected meningococcal septicaemia, an infectious disease that
affects people of all ages but is most prevalent in children under five years of age. Meningococcal septicaemia is a rare but dangerous
disease, with a mortality rate of approximately 10 per cent. It can cause rapid deterioration in the patient’s condition, so early recognition
and appropriate pre-hospital treatment is crucial. Meningococcal septicaemia is indicated by the presence of a non-blanching rash and
other signs/symptoms including: increased respiratory rate, heart rate and temperature, photophobia, mottled skin, delayed capillary refill,
joint pain and lowered oxygen saturation.
The audit assessed if benzylpenicillin use was indicated in the patients that received it, as well as assessing if the drug was given as per
JRCALC Clinical Practice Guidelines and whether patients were conveyed to hospital with a blue alert.
What the clinical audit found:
•
A non-blanching rash was documented in 57 per cent of cases. However, on examination of all the documented signs and
symptoms on the PRF, benzylpenicillin administration was found to be indicated for all but one patient in the audit.
•
92 per cent of patients received the correct drug dose for their age.
•
Only 35 per cent of PRFs documented the drug/water mix used for reconstitution of the drug.
•
75 per cent of patients were transferred to hospital with a blue alert, and where this happened patients arrived at hospital on
average four minutes earlier than for those where a blue alert was not placed.
Conclusions and recommendations:
Although benzylpenicillin is generally being administrated in the correct dose, crews should be reminded of the drug reconstitution
protocols (600 milligrams dissolved in 9.6ml water for injections for IV injections or 600 milligrams dissolved in 1.6ml water for injections
for IM injections) and the importance of accurately documenting all details of drug administration (time of administration, dose, route and
volume of water for reconstitution).
•
Crews are reminded that all patients with suspected meningococcal septicaemia should be rapidly transported to hospital with a
blue alert, and if possible all treatments other than correcting airway and breathing problems should be carried out in transit.
•
Where a patient has suspected meningococcal septicaemia but no non-blanching rash, crews should discuss the case with the
Clinical Support Desk but not delaying on scene.
For further information, or a copy of the report, please contact CARU on 020 7783 2504 (or see the X:\Clinical Audit & Research
Unit\Clinical Audit Reports).
-4-
Clinical update
Spinal injuries
in older patients
Falls are a common problem in older people and are a common reason for 999 calls. Often, there are no
significant injuries, and the patient can be left at home after a thorough assessment.
Degeneration of the vertebral column is common; at the same time, there is often a reduction in flexibility.
This means that fractures are fairly common after relatively low mechanism injuries.
When assessing the older patient who has fallen, it is essential to establish whether or not they have neck pain. It is often not possible (and probably
inappropriate) to try and distinguish between ‘old’ and ‘new’ pain. If there is any doubt, and especially if there is any weakness, numbness or other
neurological signs, the patient should be immobilised and transported to hospital for formal assessment. It is important to consider possible medical
causes of the fall, such as an arrhythmia, STEMI, stroke or black-out, although finding one of these does not eliminate injury!
Have a very low threshold for immobilisation in the patient who either says that things ‘just don’t feel right’, has vague signs and symptoms, or who is
unable to give a clear mechanism, and may be impaired through dementia.
Immobilising the patient with a fixed curvature of the spine may present a significant
challenge to ambulance crews. It may not always be possible to get a cervical collar to fit
correctly, and lying the patient down on the scoop stretcher may reveal a gap behind the
head and neck.
Do not forcibly restore the head to a neutral position.
In cases such as this, you may need to be fairly creative in how you immobilise and support
the head and neck. Consider using blankets or other padding to provide the most
comfortable support that you can. A Vacuum splint can often be moulded to fill the gap and
provide comfortable support.
It is important to remember that older patients, especially if they have a degree of dementia
may become very distressed when immobilised in a supine position. It may be appropriate to
loosen straps and tape, at the same time as doing your best to reassure the patient.
It is also essential to minimise the time that the patient spends on any form of rigid
Neck injuries in intoxicated patients
stretcher. Aim for a smooth journey to hospital and a rapid transfer onto a hospital
Remember that it is not possible to clear the cervical spine
bed.
of an intoxicated patient. Their recollection of events,
answers to direct questioning and response to physical
As well as documenting your findings on the PRF, be sure to document how you
examination may well be unreliable.
have immobilised the patient, especially if it has proved to be difficult and how you
have extricated them from the house.
In the presence of a significant mechanism of injury, the
Finally, consider the environmental circumstances of the fall – Is the environment
head and neck should be immobilised.
safe, or is another fall highly likely? If in doubt, complete a vulnerable adult referral
form, and / or consider a local falls referral.
Placental abruption
In placental abruption the placenta prematurely separates from the uterine
wall and the foetus is starved of oxygen and blood is lost from the maternal
circulation. The placental separation may be partial or total. Separation can occur
during the antenatal period, during labour and birth. The
placenta may spontaneously separate with no known cause, following trauma or a
rise in blood pressure. The women often reports increasing abdominal pain and
may report pain elsewhere. If the woman is contracting but pain persists this
should alert crews. Maternal observations may remain normal for a time but the
pulse rate will increase with a decrease in blood pressure before maternal
collapse. Mother / infant mortality and morbidity is high and rapid blue light
transfer is required to the nearest maternity unit. Foetal wellbeing is assessed in
hospital and is an important priority. If a midwife has been requested but abruption
is suspected, do not await attendance or delay life saving transfer.
-5-
Clinical update
Headaches
Neurological
examination
•
Mental state
•
Cranial nerves
•
Motor
•
Sensation
•
Headaches are a common medical presentation and are often
benign. Although occasional they can indicate a serious
underlying pathology. This article provides some bullet points
around examination and history taking in patients who present
with a headache as well as some common red flags.
History
Reflexes
Cerebella
Plantars
Red flags
•
Onset
•
Site
•
Weakness,
clumsiness, or
loss of
balance
•
Thunderclap
Most severe headache
Neck pain/stiffness
•
Any head injury?
•
Don`t be
Impaired consciousness
Medication
AVPU
GCS
FAST
•
distracted by
Visual disturbance
alcohol
Unilateral weakness
Change in usual
Vomiting
headaches?
Headache emergencies
l subarachnoid haemorrhage
l
meningitis
l
headache of raised intracranial pressure
Less urgent causes
l
l
l
sudden onset
l
maximum intensity
immediately/minute
l
worst headache ever
l
like being hit on the back of
the head with a hammer
l
small warning headaches
days before large bleed
l
associations
migraine
tension
It can be hard to distinguish a first attack or a
bad episode from subarachnoid haemorrhage.
l nausea and vomiting
l
Pressing or tight nature last 30 minutes
l
to seven days mild to moderate
intensity/normal/neurology/stress/
l
headache slower onset
l
aura warning eg visual most common
flashing lights, facial numbness, strange
noises
l unchanged by activity
l no photophobia
l no nausea or vomiting
l no neurological signs
l
vomiting, weakness, numbness,
paraesthesiae
l
no neck stiffness / or rash
Raised BP & slow pulse = Raised intracranial pressure
Temperature = Infection (meningitis, encephalitis, septicaemia,
brain abscess)
-6-
l loss of consciousness
l photophobia (intolerance
of light)
l
signs of meningeal irritation
l neck stiffness
l positive Kernig’s sign
One of the physically
demonstrable symptoms of
irritation of the meninges is
Kernig's sign. Severe
stiffness of the hamstrings
causes an inability to
straighten the leg when the
hip is flexed to 90 degrees.
Clinical update
Anthrax in IV drug users
There have been a number of cases of anthrax infections
in IV drug users (IVDU) initially reported in Scotland but
now a number of cases have been reported in London.
Staff should be aware of the possibility of anthrax infection
in IVDUs presenting with severe soft tissue infections or
sepsis. Please notify any cases of severe soft tissue
infection or sepsis in an IVDU, who died or have been
sufficiently unwell to require admission to the Clinical
Support Desk who will arrange reporting, to Health
Protection Unit.
The soft tissue infection of anthrax may reveal itself to
ambulance staff as a relatively painless boil-like lesion.
After a few days this lesion may present with a black
centre (see picture below). It can also often look like
‘mould on a piece of bread’. Cutaneous anthrax is rarely
fatal if treated, but without treatment cases can progress
to toxic shock and death.
Q1. What is anthrax?
Anthrax is a very rare but serious bacterial infection caused by
the organism Bacillus anthracis. The disease occurs most often
in wild and domestic animals in Asia, Africa and parts of
Europe; humans are rarely infected. The organism can exist as
spores that allow survival in the environment, eg in soil, for
many years.
Q2. How does anthrax usually affect humans?
There are three classical forms of human disease depending
on how infection is acquired: cutaneous (skin), inhalation and
ingestion. In over 95 per cent of cases the infection is
cutaneous, generally caught by direct contact with the skin or
tissues of infected animals. Inhalation anthrax is rare and is
caught by breathing in anthrax spores. Intestinal anthrax is very
rare, and occurs from ingestion of contaminated meat or
spores.
Q3. How has anthrax been infecting drug users?
There is an ongoing outbreak of anthrax in heroin users in
Scotland and this may be related to cases in London. Since
December 2009, a significant number of Scottish heroin users
have been found to have anthrax infection. A number of these
people have died. It is thought that they contracted anthrax
after taking heroin contaminated by anthrax spores and this has
caused innoculational anthrax which causes severe disease
and is different to classical cutaneous anthrax.
Q4. How long can you have the infection before developing
symptoms?
This is dependent on the dose and route of exposure and may
vary from one day to eight weeks. However, symptoms usually
develop within 48 hours with inhalation anthrax and one to seven
days with cutaneous anthrax. It is not known exactly how long
symptoms take to develop following the use of contaminated
heroin, however in most cases during the current outbreak,
symptoms started within one to seven days of taking heroin.
Q6. What are the symptoms?
Early identification of anthrax can be difficult as the initial
symptoms are similar to other illnesses.
Symptoms vary according to the route of infection:
Cutaneous anthrax - local skin involvement after direct contact.
Commonly seen on hands, forearms, head and neck. The lesion
is usually single. One to seven days after exposure a raised,
itchy, inflamed pimple appears followed by a papule that turns
vesicular (into a blister). Extensive oedema or swelling
accompanies the lesion – the swelling tends to be much greater
than would normally be expected for the size of the lesion and
this is usually PAINLESS
The blister then ulcerates and then two to six days later the
classical black eschar develops. If left untreated the infection
can spread to cause blood poisoning.
Symptoms of inhalational anthrax
Inhalational anthrax - symptoms begin with a flu-like illness
(fever, headache, muscle aches and non-productive cough)
followed by severe respiratory difficulties and shock two to six
days later. Untreated disease is usually fatal, and treatment must
be given as soon as possible to reduce mortality.
Q7. What is the risk to staff?
A person can get anthrax if they inject, inhale, ingest or come
into direct physical contact (touching) with the spores from the
bacteria. These spores can be found in the soil or in
contaminated drugs but may also be released from specimens
from an infected person cultured in the laboratory. Blood and
body fluids from an infected patient do not pose any risk of
inhalational anthrax, but may pose a hypothetical infection risk of
cutaneous anthrax especially through a needlestick injury or
scratch or break in the skin. The infection risk can be greatly
reduced by standard effective infection control practices.
It is extremely rare for anthrax to spread from person-to-person
and the risk to staff from an infected patient is minimal.
Airborne transmission from one person to another does not
occur. There have been one or two reports of spread from skin
anthrax but this is very, very rare.
Q8. Can anthrax be treated?
Cutaneous anthrax can be readily treated and cured with
antibiotics. Mortality is often high with inhalation and
gastrointestinal anthrax, since successful treatment depends on
early recognition of the disease.
-7-
Clinical update
Answer from last edition’s major trauma
scenarios
Scenario 1
Scenario 2
• 25-year-old
• Motorcyclist vs car 40 mph bull’s-eye to the windscreen
• Airway Patent, Breathing Resp 24 Spo2 100% (100% 02),
• 45-year-old
• Tripped over kerb and hit head on pavement
• Airway Patent, Breathing Resp 20 Spo2 98% (air), Circulation
•
•
•
•
•
•
•
•
Circulation Pulse: 110 B/P: 140/100
GCS 10 (Eyes 3, Verbal 2, Motor 5)
Has obvious fractured lower limb
St Somewhere Trauma Unit 10 minutes
St Elsewhere Major Trauma Centre 20 minutes
Scenario 1 Questions & Answers
•
Should I use the trauma decision tree?
o Yes the trauma decision tree should be used in the
context of major trauma
• Trauma centre or major trauma centre?
Scenario 2 Questions & Answers
• Should I use the trauma decision tree?
o
If appropriate which part of the decision tree does the
patient flag on?
o Reduced GCS less than 14
o
o Yes, the Blue call should be placed on PD09
Trauma unit
• If appropriate, which part of the decision tree does the patient flag
on?
o The trauma tree should not be used for this incident as the
trauma decision tree should only be used in the context of
major trauma
• Do I need to contact the Clinical Coordination Desk?
• The patient is in North West London - where should they go
No, the trauma decision tree should be used in the context of
major trauma only.
• Trauma unit or major trauma centre?
o Major trauma centre
•
Pulse: 98 B/P: 168/98
GCS 10 (Eyes 3, Verbal 4, Motor 6)
Has deep laceration across for head
St Somewhere Trauma Unit 8 minutes
St Elsewhere Major Trauma Centre 14 minutes
• Do I need to contact the Clinical Coordination Desk?
o
until October 2010?
o The nearest open major trauma centre
Only if additional help or advice is required
• Where can I get help or additional advice from?
o Clinical Coordination Desk
ECG of the Month
This ECG belongs to an 86-year-old female who had a history of
hypertension. She woke from sleep with shortness of breath and had a
blood pressure of 178/100 and oxygen saturations on air of 92%
What does this ECG show?
Where should this patient be conveyed?
-8-